You pays your money and they takes their choice

My shameless misquote in the above title requires my apologies to whomever first came up with the original line ‘you pays yer money and you takes yer choice’. Its first recorded use was as a caption to a Punch cartoon in the mid-19th century, but its relevance is so universal it was later appropriated by no less than Mark Twain (in Huckleberry Finn) and Aldous Huxley (in the preface to Brave New World).

A lot of water has passed under the proverbial bridge since the dark days of 2014, when relations between the dental profession and its regulator were arguably at their lowest ebb. The BDA’s successful Judicial Review of the GDC’s 2014 consultation on the level of the annual retention fee (ARF), the truly ghastly end-of-term performance report by the Professional Standards Authority, and GDC’s public garrotting at the hands of the Health Select Committee, all seem a long way from Shifting the balance and light years away from the content of the GDC’s latest consultation: Clear and certain: a new framework for fee-setting.

This current consultation is as significant for its style as for its actual content and purpose. The approach feels more open and transparent and less prone to preaching and proselytising than many of the documents that preceded it. It is also convincing as an attempt to engage with registrants over an inevitable potential flash point, namely the ARF. Not the actual level at which the ARF is set, but the underlying process and the premises underlying the ‘formula’ for its calculation.

There are currently around 40,500 dentists paying an ARF of £890 each, and around 70,000 DCPs in six sub-groups paying a flat rate of £116 each. It costs an additional £345 (per speciality) to be included on a specialist list for the first time and £72 a year to retain each specialist registration. By the nature of their extended multidisciplinary training, it is not unusual for specialists in restorative dentistry to also be specialists in sub-specialties. They must really look forward to their Christmas and new year break, knowing how much they are due to pay the GDC.

Fair’s fair

Which brings me to one of the big questions in this consultation – the equitable apportionment of GDC costs between different groups of registrant and the extent to which cross-subsidies are fair and justifiable. The GDC starts from the premise that each registrant group should in principle pay its own way – even if it then goes on to explain why this has not been happening up to now. But on the fringes of that sits a second question of whether it remains fair that registrants should be subsidising services being provided by the GDC for those who are paying nothing towards the costs.

The GDC proposes that one such group (those applying for GDC registration) should in future be charged a non-refundable fee for processing an application. It intends that this charge should be payable for each and every application, partly to deter serial applicants who have no realistic prospect of ever becoming registered here. I was shocked to see that 20% of all applications are refused, the admin cost of which is currently borne by UK registrants. But the GDC pays for the Dental Complaints Service out of the money paid by registrants and offers access to the service free of charge to the dental corporates, who can own and operate practices but are not required to pay an ARF.

The GDC acknowledges the various lobbies for the ARF to reflect hours worked and/or levels of income, and/or a facility for payment by instalments. A sound, well-explained case is argued for its plan to maintain the status quo in most of these respects.

It does less well in explaining why it chooses not to offer a ‘non-practising’ registration, which leads to many experienced dentists becoming de-registered prematurely and unable to play any further part in owning or operating a dental practice, even when they have no intention to treat any patients personally – unless the practice operates as a corporate body, ironically.

The 2014 car crash occurred in part because the industrial-scale uplift in the ARF proposed for 2015 was predicated on the basis of the budget that the GDC had prepared for 2015, and that in turn was predicated upon a predicted blow-out in the already-high cost of fitness to practise. Which in turn was predicated upon the continuance of a relentless increase in the number of cases reaching the GDC.

The GDC looked foolish then not just because the BDA’s legal challenge was vindicated, but because so many of the budget assumptions proved to be so wide of the mark. The GDC increased the 2015 ARF by just 55% rather than the 64% originally proposed, and within three years the caseload has fallen back to 2013 levels, FtP costs are better controlled and the GDC’s reserves are restored and spilling over.

We are all capable of understanding that the GDC cannot be 100% certain how many registrants there will be, nor how many cases will reach the expensive stages of FtP. It proposes to use its reserves to smooth such unforeseen volatility, an approach that smacks more of normal, prudent housekeeping than rocket science. I am not sure, however, that it is the GDC’s legitimate role to concern itself with ‘barriers to entry’ to the career pathways for some of the smaller registrant groups, which is a stated consideration in the context of how heavy and volatile the cost burden would be if the full cost of regulating these groups were to be met by the registrants in these groups themselves.

Follow the money

This consultation document includes not a detailed budget, but a simple high-level summary of how the GDC’s income is spent. The ‘enforcement’ cost collectively consumes just over half of the money collected. A lower proportion than in the recent past but still one hell of a slice.

The GDC alludes again to its existing but as yet unused powers to recover prosecution costs from registrants who are ‘successfully’ prosecuted. I know from my former life in the indemnity world that this is a slippery path indeed, with all kinds of unintended consequences, and the GDC is wise to continue its policy of ‘parking’ that option.

The GDC’s view is that a budget is a snapshot with a specific 12-month intent and currency, and it is no rational basis for a medium-term plan. The GDC and its registrants need and deserve greater security and ability to plan ahead.

I agree with this view along with the entirely rational proposal that future ARF consultations should be on the basis of a three-year corporate plan. This would help to avoid ‘token’ and rushed consultations and sudden shocks.

In a thinly-veiled side-swipe at the BDA and its surgical dissection of the GDC’s flawed 2015 budget at the time, the GDC cannot resist expressing its view that a ‘narrower and less productive discussion of individual budget lines’ obscures the opportunities for all interested parties to play their part in keeping GDC costs down.

If you were one of the people who lambasted the GDC in 2014/15 for behaving like an arrogant, unelected and unaccountable tyrant, this may be a good time to read what the GDC has to say in this consultation, consider the questions asked and let them know what you think about this proposed new approach to setting the ARF.

It may not yet be a fully-developed ‘brave new world’ of dental regulation, but there is a whiff of change in the air and Huxley would surely approve. After all, he wrote that: ‘Chronic remorse, as all the moralists are agreed, is a most undesirable sentiment. If you have behaved badly, repent, make what amends you can and address yourself to the task of behaving better next time. On no account brood over your wrongdoing. Rolling in the muck is not the best way of getting clean.’